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Home > Article Categories > Medical Vocational Articles > 5 Helpful Tips on Surgery Center Coding and Billing

5 Helpful Tips on Surgery Center Coding and Billing


The team brings you five ambulatory surgery center coding and billing tips.

1. Utilize modifiers that satisfy payer guidelines. According to the director of A/R for NMBS, Mr. Ryan Flesner, particular carriers have various choices when it comes to modifiers, and coders must know which carriers favor which modifiers before they hand in a claim. Modifier choices can vary by carrier and by state, so coders must do their research to prevent turned down claims.

If coders are oblivious of a carriers favored modifier, he says they can reach the carrier and deliberate how the claim should be submitted. Once the center sees a denial, the A/R rep should be able to pinpoint what brought about the denial and allow the coder know the carrier?s favored modifier.

2. Learn the electronic trail of claim submissions to every payer. The president and CEO of NMBS, suggests that billing managers map out the trail of electronic claim submissions for each payor. Electronic claims are transmitted from providers to the providers? EDI Company and, in some situations, on to a number of trading partners before the claim makes it to the payor. There is more opportunity for errors, the longer the trail of the claim goes through. To illustrate, an ASC may utilize an EDI company that does not have a direct contract with a particular payer. Having this kind of situation, the EDI Company would transmit the claim to a trading partner, which may or may not have a direct contact with the payer. If the trading partners do not have a direct contract, the claim would go to still another trading partner before reaching the payer. Keeping up on the trail of claims can also give billers a better knowledge of how long claims will take to reach payers, according to Ms. Rock.

Billing managers can start to outline the trail by following a claim form the healthcare provider to the provider?s EDI Company and then find out if the claim goes directly to the payer or to another clearing house or trading partner. "For each payer, call your EDI provider and ask if they have a direct contract with that payer. If they do not, ask where they send the claims next," says Ms. Rock. "After you determine where it goes next, call there and ask if they have a direct contract with the payer, and so on."

3. Remember to verify and authorize insurance. It is without a question important to make certain the patient absolutely has coverage before going through a procedure, according to Mr. Flesner. If the patient lacks the necessary benefits, you will get a denial. While benefits are being checked, you should always scrutinize the deductible to learn if the patient has a "trash plan," which means a very low premium and a very high deductible. Mr. Flesner advises you also not to forget to confirm benefits in an outpatient surgery center preferably than just outpatient ? there is a difference.

Confirming insurance means trying to reach the carrier directly for facts regarding the patient?s plan, the forthcoming procedure, and the essential authorization. In the midst of this conversation, the carrier can inform you the best way to submit the claim and where to send it to guarantee it is paid. According to Mr. Flesner, some insurance companies follow high-volume surgeries to guarantee surgery is important for the condition. "Carriers are going to look for a history of a more conservative approach before they offer surgery," Ms. Rock says. "That's why authorization is so important for some procedures, because maybe carpal tunnel doesn't require authorization today but tomorrow it will."

4. Money will be lost if your codes aren't in the correct order. The moment you have set down the operative report and you are now familiar which codes to bill, it?s important to place your codes in the appropriate order, Ms. Rock says. Make certain you list your codes from highest to lowest reimbursements so that you don?t lose money needlessly. For example, Medicare will lessen the procedure you list second by half, so if you have one procedure listed at $1,000 and another listed at $750, you want the reduction to be taken on the $750 procedure so that you lose less money.

It may be doable to adjust your reimbursement if you commit this error, however Ms. Rock advises making it right the first time to save yourself a lot of inconvenience. "It's always possible [to fix it], but if you sequence properly the first time, you won't have that problem on the back end," she says.

5. Knowing your managed care contract is crucial. According to Ms. Rock, your biller should have a copy of every managed care contract and make sense of the details of each one. "You need to understand how long you have to submit a claim, how long you have to review an adjudicated claim, what the payment methodology is, why a carrier would reduce multiple procedures and how to appeal a claim that hasn't been paid correctly," she says. Your ASC should utilize your managed care contract to bill out, post payments and make inquiries, and you need it in each point of the revenue cycle. For example, by carefully reading your managed care contract, you will refrain from taking an orthopedic case with a $2500 implant attached when the carrier you use doesn?t reimburse implants.

This concern can be resolved by simple research. Make certain you have your contacts handy and consult to them often. Knowing the ins and outs of your contract can assist you in saving money and making you know the score on which procedures are most lucrative to your center.



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